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what circumstances would a person born before 1957 need MMR
Most persons born before 1957 are assumed to be immune to measles,
mumps, and rubella because of the likelihood that they had the
natural diseases. But adults who are at increased risk for exposure
to and transmission of measles, mumps, and rubella should receive
special consideration for vaccination. These persons include
international travelers, persons attending colleges and other
post-high school educational institutions, and persons who work
at health-care facilities. In addition, all women of childbearing
age should be considered susceptible to rubella unless they
have received at least one dose of MMR or other live rubella
virus vaccine on or after the first birthday, or have serologic
evidence of immunity. Birth before 1957 is not acceptable evidence
of immunity for women who could become pregnant. ACIP
MMR Recommendations (see pages 16-17) (2/27/03)
long should pregnancy be delayed after MMR vaccination?
Women of child-bearing age should be counseled not to become
pregnant during the 4 weeks after MMR vaccination. (This recommendation
changed in 2001; prior to that it was 3 months.) MMWR
Notice to Readers: ACIP Recommendation for Avoiding Pregnancy
after Rubella-containing Vaccine (2/27/03)
MMR vaccine contain fetal or embryonic tissue? If so, what kind?
The rubella vaccine virus is cultured in human cell-line cultures,
and some of these cell lines originated from aborted fetal tissue,
obtained from legal abortions in the 1960's. No new fetal tissue
is needed to produce cell lines to make these vaccines, now
or in the future. Fetal tissue is not used to produce vaccines;
cell lines generated from a single fetal tissue source are used;
vaccine manufacturers obtain human cell lines from FDA-certified
cell banks. After processing, very little, if any, of that tissue
remains in the vaccine. NIP
Human Cell Cultures Webpage and Summary
of Vaccine Contents (2/27/03)
it acceptable to give single-antigen measles for the second
Yes. ACIP recommends the combined MMR, but any measles-containing
vaccine is acceptable. (2/27/03)
we see patients who have received a single-antigen measles vaccine
or a measles-rubella vaccine. Do they need one or two MMRs?
As long as the measles-containing vaccine was a live vaccine
administered on or after the first birthday, then only one MMR
is necessary. ACIP
MMR Recommendations (see page 11) (2/27/03)
a child develops a fever and rash 10-14 days after MMR #1, does
the child need a second dose of MMR at school entry?
It would be difficult to definitely say that the rash is vaccine
related. The child could have a rash totally unrelated to measles.
We recommend that you administer the 2nd dose of MMR. (2/27/03)
measles disease exacerbate tuberculosis? Does this apply to
MMR vaccine also?
Measles disease can cause a person with a latent tuberculosis
infection to develop active TB. Persons under treatment for
tuberculosis have not experienced exacerbations of the disease
when vaccinated with MMR. Although no studies have been reported
concerning the effect of MMR vaccine on persons with untreated
tuberculosis, a theoretical basis exists for concern that measles
vaccine might exacerbate tuberculosis. Consequently, before
administering MMR to persons with untreated active tuberculosis,
initiating antituberculous therapy is advisable. Tuberculin
testing is not a prerequisite for routine vaccination with MMR
or other measles-containing vaccines. ACIP
MMR Recommendations (see page 34) (2/27/03)
new employees must show proof of immunity to measles. What is
considered acceptable evidence of immunity?
In the ACIP recommendations for Immunization of Health Care
Workers, measles immunity is defined as:
a) physician-diagnosed measles;
b) laboratory evidence of measles immunity (persons who
have an “indeterminate” level
of immunity upon testing should be
considered nonimmune); or
c) appropriate vaccination on or after the first birthday of
two doses of
live measles vaccine separated by at least
ACIP Immunization of Healthcare Workers Recommendations
(see page 24) (2/27/03)
a dose of single-antigen measles vaccine given in Mexico be
counted as valid?
You can count a single-antigen measles dose from Mexico or any
other country, as long as it was not given before the first
birthday, as one of the two recommended doses of measles vaccine.
The second dose should be an MMR given at least 28 days after
the first dose and preferably at 4-6 years of age. ACIP
MMR Recommendations (see page 11) (2/27/03)
you consider a person who has received two doses of MMR vaccine
to be immune even if their serology for one or more of the antigens
comes back negative?
There is no ACIP recommendation for this situation. A negative
serology would more likely be due to an insensitive test than
true vaccine failure. However, there is the possibility, however
unlikely, of a 2-dose vaccine failure. We would recommend that
you give one more dose of MMR and stop testing. (2/27/03)
clinic serves Mexican immigrants. Should we offer MMR to the
parents who bring their children to the clinic?
This is really is a policy issue as well as an immunization
issue. You need to discuss with your agency or your state immunization
program whether you can provide immunizations to adults. If
we're talking about the VFC program, only persons 18 years of
age and younger are eligible. It is certainly advisable that
whenever possible you assess the immunization needs of the entire
family and give the vaccines indicated if your program allows.
If not, then they should be referred to a health-care facility
where they can be vaccinated. (2/27/03)
is there a two-dose recommendation for MMR but not for mumps
First, measles is more contagious than mumps or rubella. But
also, the ACIP made the two-dose recommendation around the time
of the measles resurgence of 1989-1991, when there were outbreaks
involving huge numbers of people. Even though we know that people
benefit from two doses of mumps and rubella as well, we've never
had the resurgence of disease or the outbreaks that we've had
with measles. There really hasn't been a reason, statistically
speaking, to make that recommendation. However, two doses of
MMR certainly doesn’t hurt. (2/27/03)
is the source of gelatin in MMR vaccine and some other vaccines?
The gelatin in the MMR vaccine is a highly hydrolyzed gelatin
of porcine origin. Merck purchases it from a safe U.S. source
(Dynagel Corporation) under the trade name “Sol-U-Pro”.
an area with immigrants and refugees that do not use birth control
for religious reasons, is it acceptable to administer an MMR
without a pregnancy test.
does not recommend routine pregnancy testing prior to MMR vaccination.
Women should be asked prior to vaccine administration if they
are pregnant or plan to become pregnant within the next month.
If the answer is no, they should be counseled regarding the
theoretical risk to the fetus and advised to avoid pregnancy
for one month (4 weeks) following vaccination. Then vaccinate
a dose of MMR is administered by the IM route, does it need
to be repeated?
No. Only Hepatitis B and rabies vaccines administered by nonstandard
routes must be repeated. ACIP
General Recommendations (see pages 13-14) (2/27/03)
it O.K. to give MMR in the thigh as long as it is given by the
the subcutaneous tissue of either the thigh or the upper-outer
triceps area of the arm is an acceptable subcutaneous injection
site for MMR vaccine, http://www.cdc.gov/mmwr/PDF/rr/rr5102.pdf
(see page 12). (8/21/03)
is the acceptable temperature range for storage of MMR vaccine?
Before reconstitution, store the vial of lyophilized MMR vaccine
at 2°-8°C (36°-46°F) or colder and protect from
light at all times, since such exposure may inactivate the virus.
MMR vaccine is a freeze dried (lyophilized) vaccine, therefore
freezing will not affect potentcy. The diluent can be refrigerated
or stored at room temperature, 15°-30°C (59°-86°F).
It should not be frozen. It is recommended that the vaccine
be used as soon as possible after reconstitution. Store reconstituted
vaccine in the vaccine vial in a dark place at 2°-8°C
(36°-46°F) and discard if not used within 8 hours, http://www.merck.com/product/usa/pi_circulars/m/mmr_ii/mmr_ii_pi.pdf.
soon can an MMR be given to a new mother who received RhoGAM
Postpartum administration of MMR or rubella vaccine to women
who are susceptible to rubella should not be delayed because
anti-Rho(D) immune globulin (human) or any other blood product
was received during the last trimester of pregnancy or at delivery.
Such rubella-susceptible women should be vaccinated immediately
after delivery and tested at least 3 months later to ensure
that they are immune to rubella and measles. ACIP
MMR Recommendations (see page 35) (2/27/03)
MMR is given 1 or 2 days before the first birthday, do you need
to repeat the dose?
Not if your state recognizes the 4-day grace period. Administering
the first MMR dose a few days earlier than the 12-month minimum
age is unlikely to have a substantially negative effect on the
immune response to that dose. ACIP recommends that vaccine doses
administered up to 4 days before the minimum interval or age
be counted as valid.
However, local or state requirements might mandate that doses
of certain vaccines be administered on or after specific ages.
For example, a school entry requirement might disallow a dose
of MMR or varicella vaccine administered before the child’s
first birthday. ACIP recommends that physicians and other health-care
providers comply with local or state vaccination requirements
when scheduling and administering vaccines. ACIP
General Recommendations (see page 4) (2/27/03)
everyone receive 2 doses of measles vaccine or just high risk
groups like college students?
Two doses of MMR vaccine separated by at least 1 month (i.e.,
a minimum of 28 days) and administered on or after the first
birthday are recommended for all children and adolescents through
18 years of age and for certain high-risk adults.
A second dose of MMR is recommended for adults who: 1) were
recently exposed to measles or are in an outbreak setting, 2)
were previously vaccinated with killed measles vaccine, 3) were
vaccinated with an unknown vaccine between 1963 and 1967, 4)
are students in post-secondary educational institutions, 5)
work in health-care facilities, or 6) plan to travel internationally.
Immunization Schedule and Adult
Immunization Schedule (2/27/03)
long should I wait to give MMR after a dose of immune globulin?
High doses of immune globulins can inhibit the immune response
to measles and rubella vaccine for 3 or more months. The duration
of this interference with the immune response depends on the
dose of immune globulin administered. Blood (e.g., whole blood,
packed red blood cells, and plasma) and other antibody-containing
blood products (e.g., IG, specific immune globulins, and IGIV)
can reduce the immune response to MMR or its component vaccines.
Therefore, these vaccines should be administered to persons
who have received an immune globulin preparation only after
the recommended intervals have elapsed. Table
4 in the ACIP General Recommendations provides suggested
intervals between the administration of antibody-containing
products for different indications and measles-containing vaccine
or varicella vaccine. (2/27/03)
MMR and varicella vaccines be given one month apart?
No. They can be given on the same day. However, if they are
not administered on the same day, they must be separated by
at least 4 weeks. ACIP
General Recommendations (see page 5) (2/27/03)
MMR and varicella vaccines be given on the same day but at different
times, e.g., MMR at 9 a.m. and varicella at 4 p.m.?
Yes, we define "simultaneous" in this context as the
same clinic day. (2/27/03)
do you do if MMR and varicella vaccines are given less than
28 days apart?
The vaccine given second should not be counted as a valid dose
and should be repeated. The repeat dose should be administered
at least 4 weeks after the last, invalid, dose. ACIP
(see page 5) (2/27/03)
you give hospital volunteers over 65 years of age measles vaccine
if they have no evidence of immunization and a negative titer?
Yes. Although birth before 1957 is generally considered acceptable
evidence of measles immunity, serologic studies of hospital
workers indicate that 5%–9% of those born before 1957
are not immune to measles. During 1985–1992, 27% of all
measles cases among HCWs occurred in persons born before 1957
(CDC, unpublished data). ACIP strongly recommends that all HCWs
be vaccinated against (or have documented immunity to) measles,
mumps, and rubella. ACIP
Immunization of Health-Care Workers Recommendations (see
pages 10, 22) (2/27/03)
59-year-old secretary in our college health clinic has a negative
titer for rubella. Should we vaccinate her?
Yes. Persons born before 1957 generally are considered to be
immune to rubella. However,findings of seroepidemiologic studies
indicate that about 6% of HCWs (including persons born in 1957
or earlier) do not have detectable rubella antibody (CDC, unpublished
data). ACIP strongly recommends that all HCWs be vaccinated
against (or have documented immunity to) measles, mumps, and
Immunization of Health-Care Workers Recommendations (see
pages 11, 22) (2/27/03)
12-month-old child recently finished a course of Synagis. When
can the MMR and varicella vaccines be administered?
Any time. Synagis (palivizumab) is a monoclonal antibody containing
only antibody to respiratory syncytial virus (RSV); hence, it
will not interfere with immune response to live or inactivated
General Recommendations (see page 7) (2/27/03)
an adult health-care worker has a negative measles titer, should
she receive one or two doses of MMR and what is the interval
between the two doses?
It depends on the person's disease and vaccination history.
If she has documentation of physician-diagnosed measles, this
is adequate evidence of immunity and no doses of vaccine are
If she has no documentation of physician-diagnosed measles but
has documentation of one prior dose of live measles vaccine
on or after the first birthday, give one dose of MMR.
If she has no documentation of physician-diagnosed measles but
documentation of two doses of live measles vaccine,
this is considered adequate evidence of immunity. The negative
titer is probably due to a serologic test that is not sensitive
enough to detect antibodies, but since a 2-dose vaccine failure
is theoretically possible we recommend you give one dose of
If she has no documentation of physician-diagnosed measles or
documentation of any doses of live measles vaccine, give two
doses of MMR separated by 28 days. ACIP
Immunization of Health-Care Workers Recommendations (see
page 24) (2/27/03)
patient received a PPD and MMR #1 on the same day. The PPD reading
indicated the need for a 2nd PPD, which should be given 2 weeks
after the 1st PPD. What do you advise to avoid a false negative,
since you recommend waiting 4-6 weeks to administer a PPD if
it is preceded by an MMR?
You should wait 4-6 weeks following the MMR vaccine to repeat
the PPD to avoid the possibility of a false negative result.
CDC's tuberculosis experts agree with the ACIP recommendation
to delay the PPD in this situation. (2/27/03)
a child (with all immunizations up to date) entering college
this Fall, and living in the dorm, the meningococcal vaccine
is recommended. It appears that the hepatitis A vaccine and
revaccination with the MMR vaccine would also be useful - what
are your thoughts?
If the student is truly up-to-date with MMR (i.e., has had two
doses), a third dose should not be needed. There is evidence
that over 99% of people seroconvert for measles after two doses,
with very high seroconversion rates for mumps and rubella as
for hepatitis A, there is no compelling reason to vaccinate
students who do not live in high-incidence states or who are
not otherwise at high risk (e.g., international travel, chronic
liver disease). Strictly as a precaution, getting the vaccine
can’t hurt, of course, but it isn’t routinely recommended.
the two-dose administration of MMR to college students who do
not have any documentation of immunity - what is the recommended
time interval between the first and second dose?
There should be a minimum of one month, which is defined as
4 weeks or 28 days, between doses of MMR vaccine. Table 1 in
General Recommendations on Immunization (page 3) provides
a list of minimum intervals between vaccine doses of routinely
recommended vaccines. (6/26/03)
understanding is that healthcare workers, including those born
before 1957 should have 2 MMR's or evidence of immunity to measles
(rubeola), or 2 live measles vaccines and are exempt to rubella.
Is this right? Please clarify.
According to Table 2 of the ACIP
Recommendations for Immunization of Health-care Workers
(HCWs), vaccination with measles live-virus vaccine should be
considered for all HCWs who lack proof of immunity, including
those born before 1957. Table 2 provides the definitions of
acceptable immunity. For mumps, adults born before 1957 can
be considered immune. For rubella, adults born before 1957 can
be considered immune, except for women who can become pregnant.
If there is any doubt about immunity, then give an MMR as long
as there are no medical contraindications. (6/26/03)
you please clarify who are the high-risk adults for whom two
doses of MMR are recommended?
born in 1957 or after who is a college student, an international
traveler, or a healthcare worker should have two doses of MMR
vaccine received after the first birthday and separated by at
least 28 days. For healthcare workers, this means any healthcare
worker who does not have evidence of immunity to measles and
who shares air with a patient/client. Some agencies choose to
do serologic testing for measles antibody. The two-dose recommendation
for high-risk adults has been in effect since 1989. The risk
for measles transmission from a healthcare worker to a patient
is not as great in a long-term care setting because most geriatric
patients are immune to measles, but it still exists. The greatest
risk for measles transmission is in emergency rooms, urgent
care centers, and physicians’ offices – wherever
you take in sick people. This happens practically every time
there is a measles importation into this country. You just don’t
want any healthcare worker walking around susceptible to measles.
serologic antibody levels are below protective levels for measles
in an adult, is it recommended that they receive a repeat MMR?
It is unusual, but vaccine failure is possible (approximately
1/10,000) following two appropriately spaced doses of live-measles-containing
vaccine. It is also possible that the laboratory test was not
sensitive enough to detect the antibody. If this situation occurs,
you can administer a 3rd MMR, document the dose and avoid further
testing. If you must have documentation of the response after
the 3rd dose, test 4 weeks after the 3rd dose when antibody
response to the vaccine will be at peak. Vaccine failure to
a 3rd dose is also possible, but even more unlikely (approximately
a person who is allergic to eggs receive MMR vaccine?
Egg allergy is no longer considered a contraindication to MMR
vaccine. In the past, egg protein was believed to be responsible
for rare anaphylactic reactions following MMR vaccine. The concern
now is that gelatin, which is used as a stabilizer in MMR, may
be the culprit. Measles and mumps vaccine viruses are grown
in chick embryo fibroblast tissue culture and don’t contain
ovalbumin. Several studies have demonstrated the safety of MMR
for persons with egg allergies. ACIP
MMR Recommendations (see page 34) (2/27/03)
a local reaction (e.g., hives) to topical Neosporin a ontraindication
or precaution to MMR?
Because MMR and its component vaccines contain trace amounts
of neomycin (25 mcg), persons who have experienced anaphylactic
reactions to topically or systemically administered neomycin
should not receive these vaccines. However, neomycin allergy
is most often manifested as a delayed or cell-mediated immune
response (i.e., a contact dermatitis), rather than anaphylaxis.
In persons who have such a sensitivity, the adverse reaction
to the neomycin in the vaccine is an erythematous, pruritic
nodule or papule appearing 48–96 hours after vaccination.
A history of contact dermatitis to neomycin is not a contraindication
to receiving MMR vaccine.
Recommendations (see pages 34-35) (2/27/03)
common are adverse reactions after the second dose of MMR?
We know that on average 95% (range, 90%-98%) of vaccinees respond
to the first dose of MMR vaccine. Therefore, only 5% (range,
2%-10%) would be susceptible to adverse events associated with
the 2nd MMR. We also know 5%-15% of those vaccinated experience
one of the more common adverse events associated with MMR (e.g.,
fever or rash). Therefore, we would expect that only about 5%
of the 5% who are still susceptible at the 2nd MMR vaccination
would experience an adverse reaction. Pink
Book Chapter: Measles (see pages 104 & 108) (2/27/03)
a child develops varicella, or is exposed to varicella, before
a dose of MMR is due, should the MMR be delayed? If a child
develops varicella, or is exposed to varicella, just after receiving
MMR, should the MMR be repeated?
No to both questions. There is no evidence that active varicella
disease interferes with the immune response to MMR. The only
contraindication that could apply would also apply for any other
vaccine: if the child is experiencing moderate to severe acute
illness, wait until symptoms abate before vaccinating. (2/27/03)
steroids given within 2 weeks of receiving the MMR and varicella
vaccines affect the immune response to these vaccines?
The exact amount of systemically absorbed corticosteroids and
the duration of administration needed to suppress the immune
system of an otherwise immunocompetent person are not well-defined.
A majority of experts agree that corticosteroid therapy usually
is not a contraindication to administering live-virus vaccine
when it is short-term (i.e., <2 weeks); a low to moderate
dose; long-term, alternate-day treatment with short-acting preparations;
maintenance physiologic doses (replacement therapy); or administered
topically (skin or eyes) or by intra-articular, bursal, or tendon
Although of theoretical concern, no evidence of increased severity
of reactions to live vaccines has been reported among persons
receiving corticosteroid therapy by aerosol, and such therapy
is not a reason to delay vaccination.
The immunosuppressive effects of steroid treatment vary, but
the majority of clinicians consider a dose equivalent to either
at least 2 mg/kg of body weight or a total of 20 mg/day of prednisone
or equivalent for children who weigh more than 10 kg, when administered
for 2 weeks or more as sufficiently immunosuppressive to raise
concern regarding the safety of vaccination with live-virus
vaccines. Corticosteroids used in greater than physiologic doses
also can reduce the immune response to vaccines. Vaccination
providers should wait at least 1 month after discontinuation
of therapy before administering a live-virus vaccine to patients
who have received high systemically absorbed doses of corticosteroids
for at least 2 weeks.
Recommendations (see page 23) (2/27/03)
a child develops a rash following MMR or varicella vaccination
but is otherwise well, can the child attend day care/school?
For MMR, it is not a problem because there is no risk of transmission
after vaccination. With varicella it is a little more complex.
You have to use clinical judgment about what you think the rash
looks like. Vaccine-associated varicella rashes tend to be mild,
maculopapular lesions that are essentially noncommunicable.
On the other hand, if the rash looks extensive, if it is vesicular,
or you think the person might in fact have breakthrough varicella
disease, the child could be infectious. It is possible to get
infected with wild virus varicella after vaccination before
the immune system has had a chance to mount an immune response
to the vaccine. The bottom line is that if it looks like chickenpox,
it should be treated like chickenpox. It would also depend on
the policy of the day care/school. (2/27/03)
is the frequency of seizures following MMR, if any?
MMR vaccination, like other causes of fever, may trigger febrile
seizures. The risk for such seizures is approximately 1 case
per 3,000 doses of MMR vaccine administered. Studies have not
established an association between MMR vaccination and residual
seizure disorders. Although children with a personal or family
history of seizures are at increased risk for idiopathic epilepsy,
febrile seizures after vaccinations do not increase the probability
that epilepsy or other neurologic disorders will subsequently
develop in these children. Most convulsions that occur after
measles vaccination are simple febrile seizures, which affect
children who do not have other known risk factors for seizure
MMR Recommendations (see page 29) (2/27/03)
it O.K. to administer MMR to a two-day postpartum woman who
is not immune to rubella if her infant is in intensive care?
Although a woman can excrete rubella vaccine virus in breast
milk and transmit the virus to her infant, the infection remains
asymptomatic and breast feeding is not a contraindication to
vaccination. Otherwise, persons who receive MMR vaccine do not
transmit measles, rubella, or umps vaccine viruses, ACIP
MMR Recommendations (see page 33). (6/26/03)
immunosuppressed children receive MMR, Varicella, and PPD and
should they receive them if they are in the household with immunosuppressed
is not a vaccine. It is a screening test for tuberculosis. It
can be administered at the same time as MMR and varicella vaccines.
Specific questions related to PPD administration should be directed
MMR and varicella vaccines should be administered to healthy
persons who live in the household with someone who is immunosuppressed.
You do not want to risk leaving the person susceptible and possibly
bringing home measles, mumps, rubella, or varicella wild virus
to an immunosuppressed person. MMR vaccine viruses are not transmitted
through household contact. Transmission of varicella vaccine
virus to a contact is not common. Most documented instances
of vaccine virus transmission have occurred when the vaccinated
person developed a rash. If the child develops a rash 7-21 days
following vaccination, it is prudent to avoid prolonged close
contact between the child and a usceptible person.
of vaccine viruses can be prolonged in persons who are immunosuppressed
or immunodeficient. Evidence based on case reports has linked
measles vaccine virus infection to subsequent death in six severly
immunocompromised persons. For this reason, patients who are
severely immunocompromised for any reason should not be given
MMR vaccine, ACIP
MMR Recommendations. ACIP now recommends varicella vaccination
of children with humoral (but not cellular) immunodeficiencies.
In addition, vaccination should be considered for children with
HIV infection in CDC class N1 or A1 who have CD4+ T-lymphocyte
percentages of 25% or higher. Additional details of these new
recommendations can be found in the ACIP
Varicella Recommendations. (8/21/03)